Healthcare Provider Details

I. General information

NPI: 1932083011
Provider Name (Legal Business Name): ELIZABETH MARLO MCCULLEN FANN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MARLO MCCULLEN

II. Dates (important events)

Enumeration Date: 08/02/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 VILLAGE DR
JACKSONVILLE NC
28546-7238
US

IV. Provider business mailing address

595 HINSON RD
DUNN NC
28334-9583
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-1400
  • Fax:
Mailing address:
  • Phone: 910-990-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5022764
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: